The James Cook University Hospital
Requires improvement

Reports

During a routine inspection

We rated James Cook University Hospital as requires improvement because:

The ratings went down for some services and domains. We rated the hospital as requires improvement for safe and well-led with effective, caring and responsive as good.

Critical care services had deteriorated significantly since the last inspection. We found them to be inadequate in Safe and requiring improvement in effective, responsive and well led. Caring remained Good. We were not assured that nurse staffing levels were always appropriate and in line with national GPICS recommendations.

There were significant challenges with access, flow and capacity within the critical care units. The bed occupancy had been consistently higher than the England average.

The critical care risk register not was reflective of all the risks we saw and areas of concern identified from performance data.

Diagnostic imaging services were rated as requires improvement overall. We were not assured staff were able to recognise incidents and report them appropriately. Staff told us lessons learned were not always shared with the whole team and the wider service. There was a shortage of radiologists which was impacting on the service.

Performance for achieving the timescales for provision of diagnostic radiology for cancer patients were not achieved.

There was a lack of evidence to demonstrate engagement with patients who used the diagnostic and radiology services.

The well led rating in surgery at both sites went down to requires improvement because numerous staff and doctors we spoke with felt senior managers above matron level were not visible, contactable or approachable.

The safe domain in medicine and urgent and emergency care at James Cook hospital went down one rating to requires improvement. Paediatric patients attending the urgent and emergency care service were not fully separated from adult patients. Dedicated paediatric areas were not secure to prevent adults from entering the area or children and young people from leaving. The designated mental health room did not meet the quality standards for liaison psychiatry services, it contained fixings and fittings which posed ligature and harm risks to patients, visitors and staff. There were shortages of nursing staff within the department; these shortages were evident on the majority of shifts and consultant cover did not meet the major trauma standard requirements.

We lacked assurance of shared learning and actions taken surrounding a serious patient safety incident in the catheter laboratory including whether staff were adhering to hospital policy surrounding swab and needle checks.

Medicines management surrounding reconciliation of patient medicines on admission was not robust. At this inspection we found the 24-hour medicines reconciliation compliance rate had deteriorated to 58.5% in (December 2018) against a trust target of 80%.

However:

Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. We observed positive, kind and caring interactions between staff and patients.

On the majority of occasions, the urgent and emergency care service was meeting and performing better than the national performance standards. Patient flow within the department was effective.

Policies and procedures were based on relevant national guidance.

Within medical care and surgery services nurse staffing was managed using recognised tools and professional judgment.

Staff identified patients in medical care at risk of nutritional and dehydration risk or requiring extra assistance at pre-assessment stage. Patients were offered support when required.

Managers at all levels in the emergency and medical care services had the right skills and abilities to run a service providing high-quality sustainable care.

In surgery the World Health Organisation safer surgery checks were embedded.

Pain was well controlled for patients and we observed good multidisciplinary working.

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During an inspection to make sure that the improvements required had been made

We inspected the trust from 8 to 10 June 2016 and undertook an unannounced inspection on 21 June 2016. We carried out this inspection as part of the Care Quality Commission’s (CQC) follow-up inspection programme to look at the specific areas where the trust was previously rated as ‘requires improvement’ when it was last comprehensively inspected on the 9-12 and 16 December 2014.

At the comprehensive inspection in 2014 the trust overall was rated as requires improvement for their acute and community services. It was requires improvement for the safe and effective key questions at both hospital locations. The remaining key questions were rated good overall. Community health services were rated good overall, with requires improvement for the urgent care centre.

During this inspection, the team looked at one key question in urgent and emergency care, medicine and outpatients at both hospital locations. One key question in children’s and young people at one of the hospitals, three key questions in end of life care at both hospitals, plus two key questions in the urgent care centre and one in community inpatients at one other location. All these services had previously been rated as requires improvement, and all came out as good following the June inspections.

We included the following locations as part of the inspection:

James Cook University Hospital

Urgent and Emergency services;

Medical Care;

Services for Children and Young People;

End of Life Care;

Outpatients and Diagnostic Imaging.

The Friarage Hospital

Urgent and Emergency Services;

Medical Care;

End of Life Care;

Outpatients and Diagnostic Imaging.

Redcar Primary Care Hospital

Urgent Care Centre;

Community Inpatients (adults).

Our key findings were as follows:

Patients received appropriate pain relief and were able to access suitable nutrition and hydration as required.

There were defined and embedded systems and processes to ensure staffing levels were safe. Nurse staffing in neonates did not fully comply with British Association of Perinatal Medicine (BAPM) standards. However, there was a period of sustained improvement in recruitment and increased staffing compliance rates since April 2016. During this inspection, we did not observe any evidence to suggest the level of nurse staffing was inadequate or caused risk to patients in the areas we visited.

The trust had infection prevention and control procedures, which were accessible and understood by staff. Across both acute and community services patients received care in a clean, hygienic and suitably maintained environment.

Patient outcome results had improved in areas of sepsis, senior review of patients in A&E with non-traumatic chest injury, febrile children and unscheduled return of A&E patients.

Staff understood the basic principles of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards and could explain how these worked in practice.

There was consistency in the checking and servicing of equipment.

Competent staff that followed nationally recognised pathways and guidelines treated patients. There was audit of records to make sure pathways and guidelines were followed correctly.

Arrangements for mandatory training were good and significant improvements had been made for staff to attend.

Medication safety was reported as a quality priority in 2016/17 and improvement targets had been set. There were improvements in the management of medicines since our last inspection particularly around effective audit and reconciliation of medicines. However, we found some inconsistencies in the storage of medicines. The trust nursing and pharmacy team acted promptly and these issues were addressed.

There was an open culture around safety, including the reporting of incidents. Staff were aware of the duty of candour and there were systems to ensure that patients were informed as soon as possible if there had been an incident that required the trust to give an explanation and apology.

The trust had commenced a significant period of transformation and organisational re-design in 2015. There was a newly established senior executive team, and there was a clear ambition from the Board to be an outstanding organisation.

From 1 April 2016, the trust had moved to a new clinical centre structure. There were five centres, which replaced the existing seven centres. Clinical leadership was strengthened.

The trust had been in breach for governance and finances; however, they had made significant progress against their enforcement undertakings for both elements.

The recent changes to the executive team were seen by staff to be very positive. There were improvements in the speed of decision-making and visibility of the senior team in clinical areas.

The trust was strengthening the patient voice and developing strategies to enhance patient and staff engagement.

We saw several areas of outstanding practice including:

The trust was developing a detailed programme around patient pathways/flow/out of hospital models. This included developing a detailed admission avoidance model to establish pilot schemes in acute, mental health, community and primary care services. This would ensure patients were virtually triaged earlier in their pathway rather than being admitted to A&E. This would support patients closer to home and in more appropriate facilities, and reserve acute capacity for patients who required it.

The Lead Nurse for End of Life Care was leading on a regional piece of work for the South Tees locality looking at embedding and standardising education around the 'Deciding Right' tools (a North East initiative for making care decisions in advance).

However, there were also areas of poor practice where the trust needs to make improvements.

In addition the trust should:

Ensure that the emergency nurse call system in wards 10 and 12 is reviewed to ensure it is fit for purpose.

Continue to review the level and frequency of support provided by pharmacists and pharmacy technicians to ensure consistency across wards.

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During a routine inspection

James Cook University Hospital was one of two acute hospitals forming South Tees Hospitals NHS Foundation Trust. The trust provided acute hospital services to the local population as well as delivering community services in Hambleton, Redcar, Richmondshire, Middlesbrough and Cleveland. The trust also provided a range of specialist regional services to 1.5 million people in the Tees Valley and parts of Durham, North Yorkshire and Cumbria. It had a purpose-built academic centre with medical students and nursing and midwifery students undertaking their clinical placements on site. In total, the trust had 1,351 beds across two hospitals and community, and employed around 9,000 staff. James Cook University Hospital had 1,046 beds.

James Cook University Hospital provided medical services, surgical services, critical care services, maternity services, children and young people’s services for people across the Hambleton, Redcar, Richmondshire, Middlesbrough and Cleveland areas. The hospital also provided emergency and urgent care (A&E) and outpatient services.

We inspected James Cook University Hospital as part of the comprehensive inspection of South Tees Hospitals NHS Foundation Trust, which included this hospital, the Friarage Hospital and community services. We inspected James Cook University Hospital on 9 to 12 and 16 December 2014.

Overall, we rated James Cook University Hospital as ‘requires improvement’. We rated it ‘good’ for being caring and well-led, but it required improvement in providing safe, effective and responsive care.

We rated surgical services, critical care, maternity and gynaecology, services for children and young people, and outpatient and diagnostic imaging services as ‘good’, with A&E, medical care and end of life care as ‘requires improvement’.

Our key findings were as follows:

Arrangements were in place to manage and monitor the prevention and control of infection, with a dedicated team to support staff and ensure policies and procedures were implemented. We found that all areas we visited were clean. Rates of Methicillin-resistant Staphylococcus Aureus (MRSA) and Clostridium difficile (C. difficile) were within an expected range for the size of the trust.

Patients were able to access suitable nutrition and hydration, including special diets, and they reported that, on the whole, they were content with the quality and quantity of food.

There were processes for implementing and monitoring the use of evidence-based guidelines and standards to meet patients’ care needs.

There was effective communication and collaboration between multidisciplinary teams.

There were staff shortages, particularly in A&E, on some medical wards and in children’s services, mainly due to vacancies for nursing staff. The trust was actively recruiting following a review of nursing establishments. In the meantime, bank and locum staff were being used to fill any deficits in staff numbers, and staff were working flexibly, including undertaking overtime.

The composite of the Hospital Standardised Mortality Ratio (HSMR) indicators was slightly higher than the national average in this trust. The Summary Hospital-level Mortality Indicator (SHMI) was as expected.

We saw several areas of outstanding practice including:

In the integrated medical care centre, a team of therapeutic volunteers had been created which was led by a therapeutic nursing sister who had been in place for 18 months. The volunteers had mandatory and dementia training and were in operation 24hours a day. The role of the volunteers was to support patients who may be living with dementia or other illnesses which affected their behaviour and level of supervision required. This included engaging with patients, such as playing board games or other interests patients may have. They also supported patients who required help with eating or wanted to explore their environment. This included supporting them overnight if they were disorientated. The volunteers predominantly worked on wards 10, 12 and 26. The team had been regionally recognised for its work.

In maternity services, the Families and Birth Forum was involved in the design of the induction of labour suite and championing the take-up of breastfeeding rates through the use of peer supporters, as well as improving information to raise awareness and promote the service to women when they had left the hospital.

In maternity services, lay representatives were actively involved in the patient experience rounds and 15 Steps Challenge – a series of toolkits used as part of the productive care work stream. The toolkits helped look at care in a variety of settings through the eyes of patients and service users, to help determine what good quality care looks, sounds and feels like.

In maternity services, a ‘baby buddy’ mobile phone app was being piloted by the community midwives to inform women of pregnancy issues, common ailments and reasons to seek advice.

We found outstanding areas of practice in the care and involvement of young people, including a young people’s unit, participation and accreditation in the You’re Welcome toolkit in four clinical areas, the development of a young person’s advisory group, inspections of services by young people and the involvement of young people in staff interviews.

However, there were also areas of poor practice where the trust needed to make improvements.

Importantly, the trust must:

Ensure there is a robust safeguarding assessment process in A&E. The safeguarding assessment tool must be consistently completed and regularly audited for all types of presentation. If there are concerns recorded in the safeguarding tool, there must be a contemporaneous (notes made at the time or shortly after an event) documented outcome within the care record.

Ensure the paediatric environment in A&E is reviewed so it is fit for purpose; including a process to make sure that robust risk assessments are readily accessible and available to all staff in the department.

Ensure that there are sufficient assisted bathing facilities and moving and handling aides within the children’s and young people’s ward areas.

Ensure the timely completion of the refurbishment of the medical block, especially wards 10 and 12, to enable people living with dementia to be cared for in a safe environment.

Ensure that staff have received an appraisal and appropriate supervision so that the trust can be assured they staff are competent to undertake their role.

Ensure that there are appropriate arrangements in place for the safe handling and administration of medication, including the reconciliation of patients’ medications that all controlled drugs are appropriately checked particularly on CCU and that medication omissions are monitored, investigated and reported in line with trust policy.

Ensure that all patients’ records are maintained up to date, including the recording of identification and stored confidentially in accordance with legislative requirements.

Ensure that the system for nurse calls is reviewed to ensure that there is no confusion over patients calling for assistance and the emergency alert for cardiac arrest potentially causing delays in treatment.

Ensure that, where a patient is identified as lacking the mental capacity to make a decision or be involved in a discussion around resuscitation, a mental capacity assessment is carried out and recorded in the patient’s file in accordance with national guidance.

Review arrangements for the recording of do not attempt cardio-pulmonary resuscitation (DNA CPR) decisions, including records of discussions with patients and their relatives to ensure that they are in accordance with national guidance.

Ensure robust monitoring of the safe use of syringe drivers, with sharing of results and learning from safety audits.

Ensure that an appropriate concealment trolley is in use for the transfer of the deceased, that risks have been assessed, and that all staff using the trolleys are aware of safe moving and handling practices.

Ensure staff receive appropriate training, including the completion of mandatory training, particularly the relevant level of safeguarding and mental capacity training so that they are working to the latest up to date guidance and practices, with appropriate records maintained.

Ensure that ward-based nursing staff are educated in the use of syringe drivers, including best practice in the use of continuous administration of medication for the management of key symptoms at the end of life.

Provide training for ward-based medical and nursing staff in the assessment of nutrition and hydration for people at the end of life and monitor how assessments are carried out and decisions made.

Ensure that resuscitation equipment in surgical wards and in outpatients and diagnostic imaging areas is checked in accordance with trust policies and procedures and that this is monitored.

In addition the trust should:

Review College of Emergency Medicine audit data to ensure that good patient outcomes are met.

Consider the commencement of a restraint-training programme for staff in A&E.

Introduce a formal toy-cleaning schedule in A&E.

Identify a formal board-level director who can promote children’s rights and views. This role should be separate from the executive safeguarding lead for children.

In medical care services, patients who are medically fit are discharged in a timely manner to the appropriate setting to reduce the number of delayed discharges.

Review the content and access of risk registers in medical care to ensure that these are robust to appropriately inform decision making regarding actions taken to mitigate any risk. Review the systems in place for learning lessons from complaints to improve the patient’s experience.

Review the progress of mitigating actions taken to prevent patient falls and the development of pressure ulcers, including ward based action plans, on medical care wards.

Review the care of patients receiving non-invasive ventilation to ensure that care is delivered in line with national guidance, particularly nurse staffing ratios.

Ensure that there are mechanisms for reviewing and, if necessary, updating patient information, particularly in the outpatients department.

Introduce patient surveys specific to the outpatients department.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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During a routine inspection

Over the last two years we have inspected every Trust registered hospital and community base. We have completed annual inspections of the James Cook University Hospital and The Friarage as well as completing themed inspections at the hospitals, which looked at both Accident and Emergency departments as well has the Trustï¿½s termination of pregnancy services. We found that the Trust encouraged us to identify any ways they could improve.

Teams of CQC staff have inspected all the locations and these teams included specialist advisors and experts by experience. Throughout the two years we have held regular meetings with Trust representatives and discussed work the Trust is completing to maintain and improve their service. We have found that over the two years the Trust has remained compliant with all the regulations.

Our central analytic team have constantly reviewed the data the Trust has submitted to the various bodies overseeing their work and used this to assess the performance of the Trust. The central team have also compared this information on performance against other Trusts both in the North East, across the country and against Trusts with similar size populations and services. The last published risk rating for the Trust placed them in band 6, which is the lowest risk rating.

We found that the Trustï¿½s quality assurance system was effective. It covered all aspects of the service and did not lose sight of the needs of the patients using the community services.

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During a routine inspection

We completed the visit with a specialist advisor who is a board level nurse who specialises in patient safety, human factors and clinical governance. Our focus was to look at whether the hospital met the treatment needs of older patients. So, we reviewed clinical areas that were more likely to be providing medical and nursing care to these patients. We followed the patient journey from admission to discharge. We went to the Accident and Emergency department, the Acute Admission's Units, wards 11 and 12, the discharge lounge. We also visited the trauma, plastics, orthopaedics and cardiothoracic outpatients as well as the radiology department.

We spoke with 22 patients, 11 relatives and 24 staff from across these wards and departments. Some of the patients were not able to discuss their experiences so we observed how these peopleï¿½s needs were met. Patients and relatives told us that they thought the care they received was of a very high standard. People said, ï¿½The staff have been so caring and understandingï¿½ and ï¿½We have never felt like a nuisance, they have all been so lovely.ï¿½

We found that the Trust had looked at how to decrease waiting times across the hospital. We saw that there was a clear process from patients being admitted, being examined and assessed and treatment plans being formulated in a timely way. We found that staff actively looked at the way they discharged patients and had taken action to ensure this was completed in a safe way.

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During a routine inspection

During this inspection we focused on how patients mental health and physical health needs were met and focused on clinical areas that were more likely to be providing medical and nursing care to patients with these needs. We went to the Accident and Emergency department, the Emergency Admission's Units, ward 24 and 33 and the neurosciences outpatients department. We also looked at how the Trust dealt with complaints.

We spoke with 18 patients and nine relatives from across these departments. Some of the patients were not able to discuss their experiences so we observed how these peopleï¿½s needs were met. Patients and relatives told us that they found the staff always treated them with respect and thought the care they received was of a very high standard. All said both doctors and nurses ensured they understood their plan of care.

We observed that staff across the departments ensured peopleï¿½s dignity was maintained. We found that staff and the Trust understood the process for obtaining patientsï¿½ consent; what to do when people lacked capacity; or were placing themselves at risk. We also found that complaint procedures were used effectively.

People said, ï¿½I went to the outpatients department where everything was explained to me in great detailï¿½, ï¿½The staff were brilliant when looking after me. When I needed help with washing they made sure that they kept me covered with sheets and towelsï¿½ and ï¿½They encouraged me to do what I could and helped me when needed. ï¿½

Inspection ratings

We rate most services according to how safe, effective, caring, responsive and well-led they are, using four levels:

Outstanding – the service is performing exceptionally well.

Good – the service is performing well and meeting our expectations.

Requires improvement – the service isn't performing as well as it should and we have told the service how it must improve.

Inadequate – the service is performing badly and we've taken enforcement action against the provider of the service.

No rating/under appeal/rating suspended – there are some services which we can’t rate, while some might be under appeal from the provider. Suspended ratings are being reviewed by us and will be published soon.

Ticks and crosses

We don't rate every type of service. For services we haven't rated we use ticks and crosses to show whether we've asked them to take further action or taken enforcement action against them.

There's no need for the service to take further action. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.

The service must make improvements.

At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.